III. Background

The Dominican
Republic: Economy and Health

The Dominican Republic shares the Island of Hispaniola
in the Caribbean with Haiti.The population of the Dominican Republic is approximately
8.5 million,with children under
fifteen representing 33 percent of the total population.[1]The country's economy traditionally depended
on the sugar cane industry, though the tourism industry and export processing
zones have been central to the country's development strategy over the past two
decades.[2]In fact, the tourism industry and the export
processing industry in the country's free trade zones were in large part
responsible for making the Dominican
Republic's economy one of the world's
fastest growing in the 1990s.[3]Since 1998, the Dominican Republic's economic
growth has dropped significantly, though it is still quite high compared to
economic growth in the region as a whole.[4]

Economic growth has not led to a notable increase in the
country's investment in its health sector.As a percentage of the gross domestic product (GDP), public expenditure
on health was consistently around 1.5 percent from 1991 to 2001.[5]This figure, compared to that of other
countries with similar levels of development, such as Colombia and Venezuela, is quite low.[6]Nevertheless, the Dominican Republic has a health
system that reaches a large proportion of the population at least for some
services.At 99 percent, the proportion
of pregnant women who receive professional maternal health care-in their home
or at a clinic-is the highest in Latin America and the Caribbean, though
maternal mortality still is higher than in Brazil, for example, where only 80
percent of pregnant women receive professional prenatal health care.[7]

Women's Status

Women in the Dominican Republic
suffer from many forms of inequality, discrimination, and social
exclusion.Even though literacy and
primary education enrollment levels in the Dominican Republic are relatively
high for both women and men,[8]
women are significantly underrepresented in the job market.Many women are subject to domestic violence
or to severe limitations of their possibilities for social interaction and
movement at the hands of their husbands or long-term partners.[9]

In a 2002 survey conducted by Measure DHS+ (DHS survey), an
international organization that conducts regular health-related surveys in a
number of countries worldwide, over half of the Dominican women interviewed who
lived in a long-term union reported that their husbands or male partners
expected them to disclose their whereabouts at all times.Eighteen percent of these women said their
husband or male partner actively limited their access to friends, and 11
percent reported that he limited their access to family as well.[10]

Limited social interaction and movement within a long-term
union may be a precursor to domestic violence, since it creates an environment
where women are expected to submit to male authority.The 2002 DHS survey found that 24 percent of
adult women in the Dominican
Republic had suffered some form of physical
abuse.[11]The same survey found that 27 percent of the
surveyed women had suffered physical, sexual, or emotional abuse at the hands
of their spouse or other partner in a long-tern union, and 5 percent suffered
all three types of abuse.[12]According to government figures, domestic
violence was the fourth leading cause of death for women in 2000.[13]In 2003, 83 percent of female homicide
victims were killed by their current or past spouses or long-term partners.[14]There are only five police stations in the country
specialized to receive complaints concerning domestic violence (so-called
"Friends of Women" stations), and only one functioning domestic violence
shelter, which is run by an NGO.[15]

Women do not have equal access to work, and are not treated
with equality in the workplace.A 2002
World Bank study showed that women earned only 76 percent of what men earned
for equivalent work (63 percent in rural areas), and were more than twice as
likely to be unemployed.[16]This was confirmed in the 2002 DHS survey, in
which male interviewees were almost twice as likely to have been employed
during the twelve months prior to the interview as female interviewees.For those married or in a long-term union at
the time of the survey, 52.3 percent of the women reported being unemployed
during the past twelve months, compared to only 3 percent of the men.[17]

Mariana Santos, an NGO health worker, explained to Human
Rights Watch that this economic inequality between women and men reinforces
male control over women in long-term unions.As she put it: "[The man] does not give her the money that she needs, he
manipulates her with money.We are a
poor country, and many women depend on [their husbands]."[18]

The women Human Rights Watch interviewed reported several
instances where control over the economic resources in the family was directly
related to physical abuse.Rosa Polanco,
for example, a thirty-year-old widow, told Human Rights Watch that her husband
hit her on many occasions "because I reproached him for giving me little
money."[19]Joel Valerio, an organizer who runs NGO
workshops on gender equality in Santiago's
free trade zones, recounted explanations he frequently heard men give at
workshops."The men say 'it is true that
we hit [women], but there are reasons: she is unfaithful, she spends too much
money. I am the man, I decide.'"[20]

For Haitian women and Dominican women of Haitian descent
living in the Dominican
Republic, the discrimination they suffer as
women is likely to intersect with discrimination because of their race or
nationality.[21]Ernestina Abreu, an NGO community worker who
assists women of Haitian descent in their access to health care, told Human
Rights Watch that the women she worked with suffer discrimination as women, as
Haitians, and because of their lack of economic resources.Abreu said that the doctors at the public
hospital made condescending remarks to Haitian women that they would not make
to Dominican women: "They say to the women: 'Go somewhere else, we don't have
services for Dominican women, so much less for you' or 'when you were doing
it [i.e. having sex], you weren't screaming, don't deny your color.'They say this because supposedly black people
don't feel pain."[22]

Women Living with HIV/AIDS

More than two million people
are living with HIV in Latin America and the Caribbean.[23]About one quarter of these people live in the
Caribbean, where approximately half of them
are women.[24]Haiti
and the Dominican Republic
are at the epicenter of the HIV/AIDS epidemic in Latin America and the Caribbean.At
approximately 2 percent of the adult population, HIV prevalence[25]
in the Dominican Republic is
second in the Caribbean only to that of Haiti.According to the Dominican Republic government,
prevalence is increasing at a faster rate among women than men.[26]

The leading cause of death of Dominican women of
reproductive age-defined as women between fifteen and forty-nine-is now
HIV/AIDS.[27]By the end of 2001, women of that age group
constituted 51 percent of all people in the Dominican Republic living with HIV
or AIDS.[28]Of those recently infected with HIV, the
proportion of women is greater.[29]UNAIDS estimates that over 70 percent of new
HIV transmissions happen through heterosexual sex,[30]which
means the proportion of women as opposed to men living with HIV or AIDS is
likely to grow.[31]

Physiological factors put women and girls at higher risk for
infection through unprotected vaginal sex, and economic inequality hampers
women's ability to negotiate condom use.Because of social expectations regarding women's fidelity, women are
often blamed for introducing HIV into their long-term union or marriage."It is easier to forgive a man for having HIV
than a woman.Men are supposed to run
around [i.e. have sex outside their marriage or long-term union]," Sergia
Galvn, director of an NGO working on women's health issues, explained to Human
Rights Watch.[32]Cristina Francisca Luis, community educator
from a Haitian-Dominican women's organization, said women even sometimes blame
themselves when they end up contracting HIV as a result of their husband's
infidelity: "The woman tells herself: 'If I had been a good woman, he would
have stayed home.'She blames
herself.'If I had been good company, he
would not have run around.'"[33]

The social bias that women are faithful and ultimately
responsible for their husband or long-term partner's infidelity compounds the
fear felt by many women of being known to be HIV-positive.The fear of HIV status disclosure is not
unfounded.The domestic AIDS law
requires sexual partner notification of people living with HIV.The law stipulates that the HIV-positive
person may notify their sexual partners themselves or may defer notification to
medical personnel.[34]This fear is further propelled by the prevalence of domestic
violence.Several women told Human
Rights Watch that their long-term partners repeatedly threatened them with
violence as retribution for having a sexually transmitted infection, including
HIV."I was always afraid.[My husband] said if you have something [a
sexually transmitted infection], I will kill you," recalled Judelka de la Cruz.[35]Rosana Ramrez had a similar experience: "He
said, you better be careful not to do anything bad."[36]Both de la Cruz and Ramrez were unable to
negotiate condom use with their husbands, whom they believed were the source of
their HIV infection.

Women are more likely to have been tested for HIV than
men-and thus probably more likely to know their status and to have their status
known by others-reinforcing the perception that they are to blame for
introducing HIV into their long-term unions.The 2002 DHS survey indicates that, at age nineteen, women were three
times as likely to say that they had been tested for HIV as men.At age forty, two-thirds of women in the Dominican Republic
said that they had been tested for HIV, whereas less than 40 percent of men
did.[37]

The relatively high proportion of both men and women who
have been tested for HIV[38]
is in part related to the fact that both men and women may be subject to involuntary
HIV testing as a condition to gain employment.[39]As mentioned, women are less likely to be
formally employed than men, but when they are, they tend to work in sectors-
such as services, tourism, and the export-processing free trade zones-where companies
are known to test for HIV as a condition for employment.[40]Many women are also tested when they use
government prenatal health care, which obviously does not apply to men.In fact, if women were not tested during
pregnancy, the likelihood of them knowingly being tested for HIV would be the
same as for men.[41]

Public Awareness
Campaigns, Sex Education, and Condom Use

The Dominican Republic has launched
several public awareness campaigns regarding HIV/AIDS, most focusing on the
elimination of common prejudices in the community regarding people living with
HIV/AIDS, or identifying certain situations of high-risk behavior.[42]While providing needed information, the
campaigns have so far generally failed to address directly the social biases
and prejudices that contribute to putting women at increased risk of HIV
infection.Only one very short campaign
several years ago, recalled only vaguely by an HIV/AIDS expert, focused on
helping women to learn condom negotiation skills.[43]

Secondary schools are required to provide sex education for
students thirteen years and older.[44]In recent years the most commonly used
textbook in public schools is a book republished in 2002 by the Presidential
AIDS Council: Learning is Living.[45]Though this book includes explicit
information on the correct use of condoms, it fails to address the barriers
that impede consistent use of condoms, especially for women.The book wrongly announces that "the vast
majority of those who are sexually active use condoms," and continues: "some
men don't like to use [condoms], principally because they don't want to look
bad in the eyes of women."[46]It also wrongly states that condom use is necessary only for "dangerous"
persons such as sex workers, men who have sex with men, and unfaithful husbands.[47]
The book presents marital sex as the safest HIV prevention option-after
abstinence-and counsels that the wives of unfaithful husbands "should be strong
and demand that their husbands use condoms," while failing to recognize that
women in many cases may be unable to demand condom use for fear of violence or
for fear of being thought unfaithful themselves.[48]

These assertions place the burden for increasing condom use
almost exclusively on women and fly in the face of reality.The use of condoms in the Dominican Republic is among the lowest in Latin
America and the Caribbean: around 2 percent
depending on the age of the individual and 1.3 percent between long-term
partners and spouses.[49]This sex education perpetuates a strong
social bias against condom use and implies that those who use condoms belong to
"dangerous" groups, with the stigma and discrimination that might entail.

Low rates of condom use in the Domincan Republic are in part
the product of social biases, most of which have been ignored or are
perpetuated by the sex education materials.Most women Human Rights Watch interviewed said they were unable to
negotiate condom use, and assumed their partners were faithful or that the men used
condoms with other sexual partners.Olga
Lpez, thirty-six, explained why she did not use condoms with her ex-husband,
who she believes infected her with HIV: "He was my partner, and that's what all
women will tell you.I did not think I
was at risk.Here we consider at risk
those who do sex work or have several partners."[50]Alesandra Ebrito, whose husband died of AIDS
four years ago, recalled: "I thought condoms were for casual sex. I thought that he was faithful."[51]Rosana Ramrez told Human Rights Watch that
her husband told her he did not need to use condoms with her, because "he says
that when he runs around [i.e. has sex with other women], he puts it on."[52]Judelka de la Cruz, thirty-one, said that her
husband accused her of infidelity or of being HIV-positive every time she asked
him to use a condom, so to avoid the accusation, she stopped asking.[53]

Public campaigns and sex education can contribute to change
the behavioral patterns that contribute to HIV transmission by challenging
popular attitudes toward, for example, condom use.To be successful, however, the campaigns and
education must take into account the behavioral patterns they propose to
change, which, in the Dominican
Republic, include extremely low use of
condoms and high levels of sexual inequality and violence against women.By failing to address these issues, the
campaigns have been inadequate.While
not necessarily directly related to such inadequacies, it is noteworthy that
surveyed women in 1996 and 2002 displayed a significantly drop in awareness
with regard to both correct and incorrect methods to prevent HIV transmission,
despite public campaigns and sex education.[54]The proportion of surveyed women who,
unprompted, mentioned condom use as a specific method to avoid HIV infection
fell almost 10 percentage points in this time period.

[9] For the purpose of this report, "long-term union" refers
to a couple who live together as if they were married, even though they may not
be legally married."Long-term partner"
refers to a person in a spouse-like relationship.

[15] Human Rights Watch phone interview with Mildred Baeltr,
head, Area of Violence Against Women [Area de Violencia Contra la Mujer],
Ministry for Women [Secretara de Estado de la Mujer, SEM], Santo Domingo, March 26, 2004.Another NGO-run shelter was expected to open
in May 2004.There are no immediate
plans for the government to run shelters. Ibid.

[16] World Bank Caribbean Country Management Unit, A Review of Gender Issues in the Dominican
Republic, Haiti and Jamaica, pp. 21-25.

[25] Prevalence refers to the percentage of HIV-positive people
in a given population.Incidence refers
to the rate at which people become infected.Studies in sub-Saharan Africa have
shown that incidence may be high or rising while prevalence is falling.See Helen Epstein, "AIDS: The Lessons of Uganda," New York Review of Books, July 5, 2001, p. 18.

[31] During unprotected heterosexual vaginal sex, women and
girls are physiologically more vulnerable to HIV infection than men and
boys.Factors that contribute to this
increased risk include the larger surface area of the vagina and cervix, and
the high concentration of HIV in the semen of an infected man.See, e.g., Global Campaign for Microbicides,
"About Microbicides: Women and HIV Risk," [online] http://www.global-campaign.org/womenhiv.htm
(retrieved April 5, 2004); Joint United Nations Programme on HIV/AIDS, "AIDS:
Five Years since ICPD-Emerging Issues and Challenges for Women, Young People
and Infants" (Geneva: UNAIDS, 1998), p. 11; The Population Information Program,
Center for Communications Programs, "Population Reports: Youth and HIV/AIDS,"
vol. 23, no. 3 (Washington, D.C: John Hopkins University, Fall 2001), p. 7.

[34] Ley 55-93 sobre SIDA [Law 55-93 regarding AIDS], signed
into law on December 31,
1993 (AIDS law), article 21.Mandatory notification of HIV test results to sexual partners may
translate into fear of HIV testing for some women, who have witnessed the
abandonment and ostracism of women living with HIV in their community.

[37] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, table
11.6.2 p. 249 and table 11.18 p. 269. The Demographic and Health Survey only
measures the extent to which the interviewees know that they have been tested
for HIV.

[38] By comparison, in the United States, approximately 45
percent of the total population (age eighteen to sixty-four) said they had been
tested for HIV in 2001.Centers for
Disease Control and Prevention, "HIV Testing United States, 2001" [online]
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5223a2.htm(retrieved April 13, 2004).In Latin America and the Caribbean,
around 20 percent of the total population said they had be tested for HIV
voluntarily in various countries across the region in the late nineties.Demographic and Health Surveys, "Data Tables
(HIV/AIDS Surveys Indicator Database)" [online] http://www.measuredhs.com/hivdata/data/start.cfm?action=new_table&userid=13599&usertabid=14901&CFID=906887&CFTOKEN=30905045
(retrieved April 13, 2004).

[39] HIV/AIDS experts agree that "HIV counseling and testing is
a critical entry point for both prevention and [antiretroviral treatment]
services."Global HIV Prevention Working
Group, "HIV Prevention in the Era of Expanded Treatment Access" June 10, 2004
[online] http://www.kff.org/hivaids/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=36965
(retrieved June 17, 2004)However, in
the case of involuntary HIV testing as a condition to retain or gain work there
is no treatment benefit to the individual who tests positive, and no prevention
benefit for the state.

[42] Human Rights Watch interview with Rosa Flores, director,
Unit for Attention to Sexually Transmitted Infections [Unidad de Attencin a
las Infecciones Sexualmente Transmetidas], Main Office on Control of Sexually
Transmitted Infections, HIV and AIDS [Direccin General de Control de las
ITS/VIH y SIDA, DIGECITSS], January 27, 2004.

[43] Ibid.Flores also did not recall the exact timing of the
campaign.

[44] Human Rights Watch interview with Irma Levasseur,
director, Office of Orientation and Psychology [Direccin de Orientacin y
Psicologa], Ministry of Education [Secretara de Estado de Educacin, SEE], January 29, 2004.Private schools may design their own sex
education programs, whereas public schools follow guidelines developed by the
Ministry of Education.Teachers may
recommend any textbook to the pupils.

[45] Ibid.The book was
initially published in the early 1990s under the coordination of Family Health
International (FHI).Human Rights Watch
phone interview with Csar Castellanos, associate researcher, National Health
Institute (Instituto Nacional de la Salud, INSALUD), Santo Domingo, April 22, 2004.